Hornell Area Humane Society
Paid
___________
Additional fees due ____________
7649 Industrial Park Rd, Hornell, NY 14843-0533
Date: ______________ Owner/Agent name: _____________________________________________________
Address: __________________________________________________________________________________
City: _________________________________________________ State: ____________ Zip code____________
Telephone number (where you can be reached immediately): _______________________________________
Animal name: ______________________________________ Species (circle):
dog
cat
Breed: ______________________________ Sex: __________ Age: ___________ Color: __________________
Date of last vaccinations: Distemper combo: _______________ Rabies: _________________ 1 3 year
Today’s visit: Surgery type: _______________ Rabies vaccination (required - $5) : ___________ 1
3 year
Optional services: Microchip ($30) ___________
Feline Leukemia testing ($20): ____________
(please check
Hernia repair ($15) _________ Flea meds (required if needed - $10) ___________
if desired)
Patient information – Please fill out:
What time did your pet last have food/water? Date: _____________________ Time: ____________________
How long have you had this animal? ___________________________________________________________
Has this pet ever had puppies/kittens? If yes, when was the last litter: ________________________________
Is there a possibility this pet has been spayed/neutered or could be pregnant? _________________________
If you have a female pet, when was the last time she was in heat? ___________________________________
Has this pet ever had a reaction to vaccinations or anesthesia? ______________________________________
Is your pet on any medications? If yes, list them: _________________________________________________
Has your animal bitten anyone in the last 10 days? ________________________________________________
Has this pet shown signs of illness in the last week such as coughing, sneezing, vomiting, diarrhea, seizures, or
been diagnosed with any contagious or life threatening disease(s) or congenital disease(s) such as a heart
murmur? If yes, list them: ___________________________________________________________________
Clinic use only
Weight: _________
Temp: _________
Pulse: _________
Resp: ____________
Physical Exam notes:__________________________________________________________________________
___________________________________________________________________________________________
Anesthesia: _________________________________________________________________________________
Pain med: _____________________________Start time: ___________________ End time: _________________
Surgery notes: _______________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
CONSENT FOR SURGICAL PROCEDURE – PLEASE READ AND INTIAL AND SIGN
CONSENT FOR MEDICAL PROCEDURE(S) – PLEASE READ, INITIAL AND SIGN
We strongly recommend your pet visit your regular veterinarian for a thorough physical exam, to discuss
your pet’s care, and to have all recommended testing performed prior to surgery. Our medical staff will
examine your pet prior to surgery however we still recommend following the recommendations of your
regular veterinarian. By signing this form you are acknowledging that you have either had your pet
examined and tested as recommended prior to surgery, or that you are waiving the right to do so, and both
acknowledge that your animal may be at increased risk of contracting disease or occurring illness or death
due to anesthesia or the surgical or medical procedures and that you understand and accept these risks and
will not hold the staff associated with the Hornell Area Humane Society liable for such outcomes.
__________ I, being of legal age (18) and lawfully authorized to make decisions for this animal authorize and
give my consent to the Hornell Area Humane Society and its agents to receive, transport, prescribe for, treat,
and/or perform sterilization surgery and vaccination to this animal.
__________ I understand that modern techniques will be used and trained staff will care for my animal, and
reasonable precautions will be used against injury, escape, illness and death or the animal. It is thoroughly
understood by me that the Hornell Area Humane Society, its staff, volunteers, and agents will not be held
liable or responsible in any manner and I assume and understand all risks involved with the procedures my pet
will receive.
__________ If a condition is discovered that requires medical attention or and additional procedure such as
the administration of intravenous fluids or medications, the veterinarian may in his/her discretion, perform
such procedure. I consent to these procedures and agree to pay any reasonable additional charges, if any.
__________ I understand that the medical staff can refuse to perform any procedure on any animal for any
reason. Such refusal is at the sole discretion of the attending veterinarian.
__________ I understand that my animal will receive a small tattoo to indicate he/she has been sterilized.
__________ I understand that my animal must be picked up from the shelter at the time designated by the
staff on the day of surgery. If I do not claim the animal, I will be charged a boarding charge not less than
$20/day. If the animal is not picked up in the time accordance with the law, the animal will be considered
abandoned and become property of the Hornell Area Humane Society and I will be responsible for boarding
charges until that time.
I , the owner/agent for this animal, understand that this is a legal document; have read it carefully; and fully
understand its content. By my signature below, I give my informed consent to all of its terms.
Signature __________________________________________
Date __________________________